Nokea
Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?
- A. The client has complaints of not sleeping well for the past week
- B. The family wants to discontinue the home meal service, meals on wheels
- C. The urine in the client has been cloudy for the last 2 days
- D. The partner says the client has slower days every other day
Correct Answer: C
Rationale: Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation.
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The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?
- A. Leave the graft site open to the air.
- B. Elevate the recipient site.
- C. Encourage range-of-motion exercises.
- D. Change the dressing twice a day.
Correct Answer: B
Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.
A client has orders for cefoxitin (Mefoxin) 2 g IV piggyback in 100 cc 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity.
It is MOST important for the nurse to take which of the following actions?
- A. Administer the medication slowly, at 25-25 cc/h.
- B. Change the primary IV solution.
- C. Hang the piggyback infusion bag higher than the primary infusion bag.
- D. Obtain an infusion pump prior to administration.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) antibiotic should be administered within one hour (2) unnecessary for safe infusion (3) correct-when using a gravity drip, piggyback fluid level needs to be higher than primary infusion (4) unnecessary for safe infusion
The nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse perform FIRST?
- A. Administer aspirin 325 mg PO.
- B. Obtain a CT scan of the head.
- C. Check the client’s blood glucose level.
- D. Start an IV line.
Correct Answer: C
Rationale: Hypoglycemia can mimic stroke symptoms; checking blood glucose is the first step to rule out treatable causes. Options A, B, and D are secondary.
The nurse is caring for a client who is receiving a continuous IV infusion of propofol (Diprivan) for sedation. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/min.
- B. Blood pressure of 100/60 mmHg.
- C. Heart rate of 80 bpm.
- D. Oxygen saturation of 90%.
Correct Answer: D
Rationale: An oxygen saturation of 90% indicates hypoxemia, a serious propofol side effect. Options A, B, and C are acceptable.
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel is an antiplatelet medication that can increase the risk of bleeding, such as epistaxis (nosebleeds). Abdominal distention, nausea, and hyperactivity are not typical adverse effects of clopidogrel, so answers B, C, and D are incorrect.